One Surgeon’s Quest to Tackle a Global Pediatric Crisis

The saying goes, “Give a man to fish and feed him for a day. Teach a man to fish and feed him for a lifetime.” But does the same principal apply to brain surgery?

Dr. Ben Warf at Boston Children’s Hospital is responsible for such innovation and he has established a neurosurgery training program to educate brain surgeons from around the world on a procedure that can save thousands of children’s lives. The first results of this program have recently been published, and the outlook is promising.

Throughout his career, Dr. Warf has been celebrated as an innovator and global health champion. As a pediatric neurosurgeon and global health worker, he has been confronted with widespread social issues and neurologic diseases, but none as formidable as hydrocephalus. This is predominately a pediatric condition caused by congenital anomalies, infections, and brain injuries.

While this disease still exists in the United States, the highest burden is found in countries in Africa and Latin America, where there is a pooled incidence of 145 and 316 per 100,000 births, respectively. If left untreated, hydrocephalus can result in cognitive dysfunction and death. Mortality rates for this terrible disease are as high as 41 percent.

Tasked with addressing these grave statistics, Dr. Warf set out to deliver care in a region of the world that needed it most: Mbale, Uganda. Here, he was part of a team that helped to established CURE Children’s Hospital in 2000. The facility treats every year more than 1,280 children with neurosurgical issues, including hydrocephalus.

The global standard of treatment for hydrocephalus is to place an internal shunt that diverts fluid from the brain to the abdominal or pleural cavity, thus alleviating intracranial pressure. Although this treatment is very effective, shunts are extremely prone to failure, with rates as high as 50 percent. In America, a child with a failing shunt can simply go to a local hospital and receive the treatment he or she needs, but shunts are extremely risky for children who live in places where access to care is scarce. Shunt failure can be deadly.

As Warf explained to me in a recent interview, “About half of these shunts fail in the first few years, and nearly all will fail at least once eventually. Some shunt-dependent children require several emergency shunt operations over their lifetime. Shunts work fairly well for children in developed countries like the United States, because we have the resources to provide emergency access to neurosurgical treatment when the shunt fails, but the story is very different in low-resource countries, where it is reasonable to assume that most shunt failures will not be addressed quickly and the result is often fatal.”

To address this problem, Dr. Warf pioneered a treatment procedure that has proven to be a promising solution to this problem. Using a flexible endoscope, a tool inserted into the head so that a surgeon can see into the brain, he can access the fluid-filled spaces within the brain and create a passageway for fluid to escape out of the intracranial space. This is called an endoscopic third ventriculostomy (ETV). He also performs a procedure called choroid plexus cauterization (CPC) which involves using a special instrument to heat up and kill the cells in the brain that create spinal fluid. The combination of these two procedures has been remarkable successful and it quickly became widely used in low- and middle-income countries around the world. Eventually, even physicians in wealthy nations such as the United States began to regularly perform ETV and CPC in combination.

Not only has Dr. Warf dedicated years to perfecting this procedure to aid in the treatment of many children at Cure Children’s Hospital, he has also established a fellowship training program, called the CURE Hydrocephalus and Spina Bifida (CHSB) Fellowship, to teach other surgeons from around the world how to do it. Prospective fellows are heavily vetted to determine whether they have the necessary background credentials and skills, whether their home region has sufficient pediatric volume and hydrocephalus burden, and whether the fellow and home institution will commit to collaborative data sharing to improve research and outcomes.

Once selected, fellows spend eight weeks at Cure Children’s Hospital in Mbale, Uganda, where they participate in anatomy review, simulation labs, daily ward and intensive care unit rounds, clinic, and in the operative suite. Under supervised guidance, the participants practice their new skills and are then able to return to their home programs and establish or rejuvenate their own pediatric practice. In addition to the surgical skills gained, fellows are supplied with an endoscope and other necessary tools to perform the procedure.

To date, over 33 surgeons from 20 low- and middle-income countries have graduated from the CHSB program. They now practice in their home counties, which include Angola, Bangladesh, the Democratic Republic of Congo, Ethiopia, Ghana, Guinea, Honduras, Indonesia, Kenya, Liberia, Nepal, Uganda, and Tanzania. Collectively, they have performed more than 2,5000 hydrocephalus operations, including 963 ETVs, thus alleviating the encumbrance of shunt dependence in those patients.

For surgeons involved in global health, the challenge has always existed to properly partner with local providers and collaborate to create self-sustaining solutions while avoiding temporary and narrow interventions and “savior complex” mission trips. Faced with high volumes of patients and limited resources, Dr. Warf has found the answer to address this problem with the combined procedure of ETV with CPC, and through his surgical-skills training program, he has also expanded his impact to other areas of the world where the need is great.